Member Materials and Forms

Here you can find important documents about your Molina Healthcare of Virginia health plan. Click the links below for more information.

Member Handbooks

Your member handbook will help you understand your benefits and how you can best get help from Molina. It explains your healthcare, prescription drug, transportation, and benefits coverage with Molina Medicaid. It tells you how best to make your health plan work for you.

Feel free to share this handbook with a family member or someone who knows your healthcare needs.

When you have a question, check this handbook, call Member Services, or call your Care Manager if you have one.

Commonwealth Coordinated Care Plus (CCC Plus) Member Handbook 2022 -- updated July 2022

Medallion 4.0 Member Handbook 2022 -- updated July 2022

Printed copies of the Member Handbook are available free of charge upon request.

Provider and pharmacy directories (Coming soon)

Printed copies of the Medallion 4.0 and CCC Plus provider directories are available free of charge upon request.

Member forms

Click on the links below to access important member forms.

Appeals forms


icon_pdf Member Appeals Form




icon_pdf Pregnancy Notification Member Form
icon_pdf Taking Care of You and Baby Flyer



Other materials

icon_pdf Medicaid Childhood Shots Schedule

Help in other languages or alternate formats

This website and other plan materials are available for free in other languages and formats including in print, large print, Braille or audio CD. To request the information in an alternate format and/or language, call Member Services. This call is toll free.

Member Services

Our bilingual staff and interpreters are trained professionals. They understand medical and treatment information. They can help you communicate with your health care professionals, your family members or your friends about treatment and medical history. And they can provide health education.

If you have any problems reading or understanding this information, please contact Member Services at for help at no cost to you.

Additionally, members with alternative hearing or speech communication needs can dial 711 to reach a Telecommunications Relay Services (TRS) operator who will help you reach Molina's Member Services. Voice and TRS users can make a 711 call from any telephone anywhere in the United States free of charge.

If you do not speak English, call Member Services. We have access to interpreter services and can help answer your questions in your language. We can also help you find a health care provider who can communicate with you in your language.

Notice of privacy practices 

This notice describes how medical information about you may be used and DISCLOSED and how you can get access to this information. PLEASE READ THIS NOTICE CAREFULLY. Or you can download and print the information:

Notice of Privacy Practices

Uses and releases of protected health information (PHI)

Molina Healthcare of Virginia believes in protecting the privacy of your health information. We may use or disclose your Protected Health Information (PHI) only for very specific reasons. PHI is any information related to health that identifies an individual. This information can be electronic or in any other format. Different types of uses and disclosures are listed and explained below. Note: An example is not given for every use or disclosure reason.

When disclosing or using PHI, we will use the least amount of information necessary. If we need to use or release information in a way that is not generally described in this notice, we will contact you for your written permission before the proposed use or disclosure.

Types of Uses or Releases of Information


We may use or disclose PHI about you to assist in providing treatment or services. Treatment means the provision, coordination, or management of health care and related services by one or more providers, including the following activities:

  • Coordinating health care or related services by a provider with a third party
  • Consultation between providers relating to a patient
  • The referral of a patient from one provider to another

For example, we may use or disclose your PHI when referring you to a particular provider to receive care.


We may use and disclose your PHI so that your treatment and services may be billed and payment collected. For example, we may use or disclose your PHI to a health care provider in the course of making prior authorization determinations under your benefit coverage.

Health Care Operations

We may use or disclose PHI to carry out health care operations. Examples of health care operations include such things as:

  • Activities to analyze trends relating to improving health or reducing health care costs (called population-based activities);
  • Case management and coordination of health care;
  • Quality assurance activities (including audits by third parties);
  • Contacting providers and patients with information about other forms of treatment.

We may use or disclose your PHI for these or other activities that fall under this definition, such as preventive treatment programs or fraud detection and investigation.

Health Oversight Activities

We may disclose PHI to a health oversight agency for compliance activities authorized by law. These activities are necessary for the government to oversee the health care system, compliance of benefits programs, and compliance with civil rights laws. Disclosures may occur through audits, investigations, licensure or disciplinary actions or civil, administrative or criminal proceedings.

Information Relating to the Treatment of Minors

Information relating to the treatment of minors will be kept private according to federal and state laws. Many states allow minors, after a certain age, to receive mental health and/or substance abuse treatment without permission from their parents. We follow all applicable laws that apply to the confidentiality of treatment for minors.

Information Pertaining to Certain Types of Treatment/Services

Information pertaining to treatment or services for some sensitive conditions, such as substance abuse, mental health, and HIV, may be subject to more restrictive privacy protections under state or federal law. Uses and disclosures of such information may be limited or prohibited by such laws in your state. For more information about these kinds of federal and state law restrictions and how they may apply to our uses and disclosures of certain PHI, please contact our Privacy Officer as noted at the end of this document.

Health Related Benefits or Services

On occasion, we may use or disclose PHI for preventive treatment reasons. Our preventive programs meet nationally recognized quality and preventive health standards.

Lawsuits and Disputes

We may disclose PHI in response to a subpoena or court order. We may also disclose PHI in response to legal cases that directly involve your health plan or us. All other disclosures for lawsuits or investigations will be made only with your written permission.

Appointment Reminders

We may use or disclose PHI to remind you of upcoming appointments for treatment or medical care or other services which pertain to you.

Treatment Alternatives

We may use or disclose PHI to let you know about other types of treatment that may be of interest to you. All such communications are handled in a manner that protects your privacy.

Release of Information to Family Members

In an emergency, or if you are not able to provide permission, we may disclose limited information about your general condition or location to someone who is directly involved in your care or the payment of your care, or who can make health care decisions on your behalf.

Release of Information to the Armed Forces

If you are or were previously a member of the armed forces, we will disclose your PHI to the armed forces as required by law. We may also disclose information as required by our contract with your armed forces health insurer. We will only release the minimum amount of information needed to carry out the purpose of the use or disclosure.

Release of Information to Workers Compensation or Similar Programs

We will not disclose PHI to workers compensation programs or other similar types of programs without your signed permission.

As Required or Permitted by Law for Public Safety

We will disclose PHI when required or permitted to do so by law for public safety. Disclosures may be made to protect you from a serious threat to your health or safety or to protect the health or safety of another person. Disclosures may also be made when requested by federal officials for national security or intelligence activities or for the protection of public officials. We will only release the minimum amount of information needed and will follow specific legal guidelines.

Government Security Clearances

We may disclose PHI when required by law for government security clearances. We will only release the minimum amount of information needed for the clearance.

Public Health Risks

We may disclose PHI as authorized or required by law for public health activities. This includes reporting child abuse or neglect, adult abuse, unfavorable events, or product defect reporting.


If you are an inmate or are in the custody of law enforcement, we may disclose your PHI without your permission. We will only do this for your health care, for the health and safety of you or others, or the safety of, or further law enforcement on the property of the correctional facility.

Psychotherapy Notes

We rarely ask for psychotherapy notes and do not disclose psychotherapy notes to any outside parties. Psychotherapy notes are defined as notes recorded by a mental health professional that consist of the written record or evaluation of the contents of a conversation during a private counseling session or a group, joint, or family counseling session. These notes must be maintained separately from the rest of the individual’s mental health/medical record. In the rare event that we do request psychotherapy notes, it will be only with your written permission.

Genetic Information

We are prohibited by law to use or disclose your genetic information for underwriting purposes.

Other Uses and Disclosures

Other uses and disclosures, including for marketing purposes or that constitute the sale of PHI, will be made only with your written permission. You are permitted to discontinue such authorization at any time in writing. Requests to discontinue permission to release information will be honored except when we have already taken action based on your permission to use or disclose the information.

Rights Related to PHI

To exercise any of the rights described below, you may contact the Privacy Officer:

Pam Daniels
Molina Healthcare
3829 Gaskins Road
Richmond, VA 23233
Office Telephone: 
(240) 495-1029

Right to Request Restrictions on Uses and Disclosures

You have a right to request limits on certain uses and disclosures of PHI for treatment, payment or health care operations. We will consider each request but we are not required to agree to any requested limits. In certain cases, limits you may wish to set on the disclosure of PHI may affect our ability to pay for your services.

Right to Receive Confidential Communications

You have a right to request that you receive confidential information relating to PHI at an alternative location or by an alternate means if sending this information by normal means could put you in danger. All such requests must be in writing and must state that the release of this information through normal means could be a danger to you. All reasonable requests will be granted.

Right to Inspect and Copy Protected Health Information

You have a right to review and ask for a copy of your PHI that is part of our designated record set. This right does not apply to psychotherapy notes, information gathered to prepare for civil, criminal or administrative actions or proceedings, or where law does not permit the release. There are also circumstances where we may deny your request. For example, there are situations in which a licensed health care professional may determine that releasing the information could have an adverse effect on you or another person.

In such cases we will not release the information; however we may be able to release some information in our records. In the case that we use or maintain an electronic health record with respect to your PHI that is part of the designated record set, you have a right to obtain your copy in electronic format. If allowed by your state law, we may charge a reasonable cost-based fee to copy, process and mail your information to you.

Right to Amend Protected Health Information

You have the right to request that we change the information that we have in our records if you believe that the information is incorrect or incomplete. We may deny this request if we determine that the records are complete and accurate, or that we did not create the information you are requesting to change. We may also deny the request if the information is not part of our official records or access is otherwise restricted by law.

Right to Receive an Accounting of Disclosures

You have a right to receive a listing of PHI disclosures made other than (i) those made for treatment, payment or health care operations, (ii) those made prior to the effective date of this notice, (iii) those made with your written permission, and (iv) those made for law enforcement or national security purposes.

Right to Be Notified of a Breach

You have the right to be notified in the event of a breach of unsecured PHI involving your information. Not all unauthorized uses or disclosures of PHI constitute a breach of unsecured PHI.

Right to Obtain a Paper Copy of this Notice

You have a right to receive a paper copy of this notice, even if you have received a copy of this notice electronically. To request a paper copy, you may contact us at:

Privacy Officer
Pam Daniels
Molina Healthcare
3829 Gaskins Road
Richmond, VA 23233
Office Telephone: 
(240) 495-1029

Our responsibilities under this notice

The law requires us to maintain the privacy of your PHI. The law also requires us to provide you with this notice of our legal duties and privacy practices with respect to your PHI. We are required to follow the terms of the privacy notice that is currently in effect. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. Should the terms of this notice change in any way that would also change your rights, we will send you a notice of this change within 60 days.

Questions and comments

Your opinion about our services is very important to us. We also want to make sure that you fully understand your privacy rights. If you want more information about Protected Health Information you can go to the U. S. Department of Health and Human Services HIPAA Privacy website at


You may file a complaint with us if you feel that your privacy rights have been violated. All complaints must be submitted in writing. To file a HIPAA related complaint, you may contact us at:

Privacy Officer
Pam Daniels
Molina Healthcare
3829 Gaskins Road
Richmond, VA 23233
Office Telephone: (240) 495-1029

You may also complain to the US Secretary of Health and Human Services via their website or at:

Office for Civil Rights
U.S. Department of Health and Human Services
Sam Nunn Atlanta Federal Center, Suite 16T70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909

You will not receive a negative reaction from us because you filed a complaint.


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